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Session 284, February 14, 2019 – 4-5 pm
Jennifer Waterbury, MSIE, CSSBB, Senior Bundled Payment Engineer, AdventHealth
Mark Hiller, Vice President of Bundled Payment Collaborative & Analytics, Premier Inc.
Navigating Multi-Hospital, Episode-Based Care Delivery
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Jennifer Waterbury, Senior Bundled Payment Engineer,
AdventHealth
Mark Hiller, Vice President of Bundled Payment Collaborative
& Analytics, Premier Inc.
Conflict of Interest
Have no real or apparent conflicts of interest to report.
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• Review Episode-Based Models and Analytics
• Collaboration & Data
• Refacing of BPIP Interface Data
• Internal Analytics Tool
• Outcomes
• Future Applications
Agenda
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• Assess episode-based care delivery modeling for a total joint
bundled payment program
• Identify analytics capabilities, education, training and process
improvements needed across multi-hospital teams
• Discuss claims analytics data optimization for bundled
payment program
• Recognize challenges with limited data that led to development of
a real-time internal bundled payment analytic tool
• Restate the benefit of standardized data and analytical support
for a multi-hospital organization to achieve success with
bundled payments
Learning Objectives
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Different Types of Data
• Blinding of Information Varies by Payer and Even Type of Contract – Paid Amounts, Provider
Blinding Challenges
• No Standard Reliable Format to Payer Claims Files – Mapping Necessary for Each New Program
• File Timing and Format Changes Inconsistent
• Federal Program Files Usually Most Transparent – Ideal Starting Files
• Claims-based Information May Differ from EHR/HIE Sourced Data – e.g. Mammogram Rate
• Claims Lag – Balance “Complete” with “Timely”
• Cost Information From Outside May Need to be “Siloed”
Different Set of Skills/Expertise
• Management of Changing or Absent Attribution in Populations
• Creation of Actionable Information from Overwhelming Data – “Bigger Haystack”
Claims Analytics Challenges
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Awards
• 2017 Bundled Payment Collaborative Member Awards
– Bundled Payment Intelligence Platform Super User Award
– Member Sharing Masters Award
• 2018 Healthcare Informatics
Innovator Award – 2
nd
Place
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Episode-Based Models
Comprehensive Care
for Joint Replacement
(CJR)
Bundled Payments for
Care Improvement
(BPCI) – Advanced
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Episode-based Care/Payment includes:
• Full continuum of care from episode start through care transitions
• Incentives for improving efficiency and care coordination
– Clinical Outcomes
– Financial Accountability
Episode-Based Analytics
Anchor
Hospitalization
(Episode
Initiator)
Anchor
Hospitalization
(Episode
Initiator)
Physician Fee
Schedule
Physician Fee
Schedule
SNF/IRF/LTCHSNF/IRF/LTCH
Home Health/
Outpatient
Services
Home Health/
Outpatient
Services
ReadmissionsReadmissions
90 days
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Comprehensive Care for
Joint Replacement
CJR: mandated model for Medicare hip & knee replacements
• Started April 2016 and continues through December 2020
• Episode: Anchor Admission through 90 days post discharge
• Target & Actual spend includes all costs (some exclusions apply)
• Reconciliation/Repayment
• Revised Dec 2017 reducing mandated Metropolitan
Statistical Areas
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• Original rule: 16 hospitals within 4 states
• No prior orthopedic bundled payment experience
– Joint Programs at some facilities
• Corporate Support and Standardization needed
– Engage with physicians, executives
– Care Coordinators, Program Managers
– Timely comprehensive data
CJR and AHS
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Data Challenges
• AHS Internal Dashboard Limitations for THA/TKA
– Only displayed 30-day readmissions
– Not tracking complication rate
– Not tracking post-acute care
• CMS data over a year old
– 3 years combined
– Multiple baseline files
– Not user friendly
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Medicare Claims Data Challenges
IPHDR File
EPI File
Have to link from IPHDR to EPI by EPI_ID
• Look at the Anchor_OP_NPI to determine the physician
– Must have a NPI list with physician names
• For patient name: use BENE_SK and BENE_HIC_Num in the DENOM file
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Overwhelming!!!
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Additional Issues
• Download of multiple files with each publication
• Incomplete due to Claims Lag
• Medicare data only published quarterly (originally)
– Now monthly
• Quality metrics not included
Medicare Claims Data Challenges
How do we know in real-time how we are performing?
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Collaboration and Data
• AHS joined Premier’s Bundled Payment Collaborative Sept. 1, 2015
• Collaborative provided access to the Bundled Payment Intelligence Platform
(BPIP)
– Bundled payment specific cross continuum claims analytics for CJR
– Became available and trained users in June 2016
• Additional efforts:
– Bi-weekly Project Status meetings to review the progress of the Comprehensive
Care for Joint Replacement (CJR) program
– Attendance at AHS Steering Committee meetings
– Gainsharing Analytics Platform (GSAP)
– AHS team serves as one of the leading examples of success for other
members of the collaborative
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CJR Reporting Interface
User Friendly By Hospital and By Physician Claims Data
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CJR Reporting Interface
This allowed us to not
have to struggle with the
Medicare claims files
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AdventHealth CJR Financials
Performance
year 2
Performance
year 2
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AdventHealth CJR Post-Acute Care
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AdventHealth CJR Patient Tracking
Dashboard
Dashboard to display near real time data for key metrics:
Calculator for predicting episode total spend, depending
upon patient type and PAC services utilized
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• Electronic Medical Record (EMR)
• Data team member(s) with understanding of multifaceted
layers of CJR
• Access to advanced data analytic tools and developer
• Collaborative Team
• Engaged Hospital CJR Program Owners
Prerequisites
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• Approval from Steering Committee
• Collaborated with leadership and CJR sites to identify key metrics
• Identify sources for data using EMR whenever possible
• Mirror criteria and timeframes from CJR Regulations and
Quality Metric specifications
• Weekly meetings with the analytics team
• Enhanced analytic team’s knowledge through a CJR site visit
• Piloted to hospitals for feedback prior to production
• Continue collaboration with analytics team for further
enhancements
Development Process
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Executive Summary
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Patient Details
Drill down to patient specific data combined
from EMR and manually submission
Care Navigator data to capture readmissions
to facilities outside of AHS
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Beneficiary Letter
Presence of scanned in
Beneficiary Letter
captured in EMR
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Complications
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Care Coordinator Data
Collected and submitted by each hospital’s
CJR Care Coordinator
Uploaded to secure FTP site for the
dashboard to easily access
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Cost Prediction Calculator
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CJR Patient Tracking Dashboard
• Go-Live
– Early 2017 (PY2)
• Data is refreshed daily
• Continual training and ad hoc phone calls
• Share standardized data at meetings
How does this benefit a multihospital organization?
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• THA/TKA Complications
– Dashboard provides up to date knowledge, instead of 2 years
behind
– Developed a Performance Improvement Project
– Identified opportunity with pneumonia complications and a
correlation with higher BMI
– Strengthening system for patient optimization
• Raw Complication within AHS facilities only
– PY 2 (FY): 3.2%
– PY 3 to date (~6-8 months): 1.5%
• Received reconciliation payment for PY 1 and PY 2
• PY 1 & PY 2 Quality was in “Good” category and are aiming for “Excellent”
Hospital A
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• Return to Hospital
– Dashboard provides up to date ED visits, Observation statuses, and
Readmissions to our own facilities
– Analyzed the reasons for return visits to see if there was
consistency and identified constipation
– Identified opportunity in education
• Beefed up pre-op class
• Going through the over the counter medications
• Raw readmissions to AHS facilities
– 2017 discharges: 18%
– April-July 2018 discharges: <10%
• Received reconciliation payment for PY 1 and PY 2
• PY 1 and PY 2 quality score categories are “Good”
Hospital B
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• Use dashboard to estimate the potential costs/spend of patient while
keeping the best outcomes in mind
– Optimize post-acute care placement
• Raw Complication within AHS facilities only | Total Claims
– 470 without fracture
• PY 1: 5.9% | $23,156
• PY 2: 0% | $22,110
• Received reconciliation payment for PY 1, projecting reconciliation
payment for PY 2
– PY 1 Quality was in “Acceptable” category
Hospital C
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PY2
• Reconciliation payment was an excess of $1.8M
– All 12 CCNs received reconciliation
• Quality
– 4: Excellent 6: Good 2: Acceptable
PY1 compared to PY2 (6 months of each)
• 13-17% decrease in acute hospital LOS
• 19% decrease in 90-day readmissions
• 17% decrease in SNF discharges
Bi-Monthly calls to review performance
including data
AdventHealth CJR Outcomes
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Success, but Still Improving
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BPCI-Advanced
• CMS released on January 9
th
, 2018
• Voluntary model
• 29 inpatient and 3 outpatient clinical
episodes
• CJR takes precedence
• Hierarchy: Attending, Operating,
then Hospital
• Effective Oct 1, 2018 through
December 31, 2023
• 90 day post discharge episodes
(like CJR)
• 20% stop loss/stop gain out the gate
(not like CJR)
• Quality metrics
• All-cause Hospital Readmission
Measure (NQF #1789)
• Advanced Care Plan (NQF #0326)
• Perioperative Care: Selection of
Prophylactic Antibiotic: First or Second
Generation Cephalosporin
(NQF #0268)
• Hospital-Level Risk-Standardized
Complication Rate (RSCR) Following
Elective Primary Total Hip Arthroplasty
(THA) and/or Total Knee Arthroplasty
(TKA) (NQF #1550)
• Hospital 30-Day, All-Cause, Risk-
Standardized Mortality Rate (RSMR)
Following Coronary Artery Bypass
Graft Surgery (NQF #2558)
• Excess Days in Acute Care after
Hospitalization for Acute Myocardial
Infraction (NQF #2881)
• ARRQ Patient Safety Indicators
(PSI 90)
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• Challenges: Data complexity and lag
• Automate data from EMR, as much as possible
– Standardized, actionable, near-real time CJR dashboard has
benefited our sites
• Involve clinical end-users to identify key metrics
• Build strong analytics team
– Site visit with data analytics team
– Validation and ongoing refinement
• Beta-testing to identify glitches and make adjustments
• Sharing best practices through a continual feedback loop
– Decreased complications and readmissions
– Collaboration across the system
Summary
